1. Topic review: evaluation of a limping child
2017/03/15
R2徐子權/CR潘妤玟/VS劉清泉

2. Case 1 A 2-year-6-month-old boy Birthday : 2014/08/22
Date of admission : 2017/03/05
Chart number:164800xx

3. Chief complaint
Right hip pain with limping gait noted for one day (since 3/04 evening)

4. Brief history
Past history of neuroblastoma, stage I s/p total excision on 2014/9/22 at NTUH, currently followed up at Dr.鄭's OPD
Playing 滑板車 on 2017/02/28
Right hip pain with limping noted for 1 day
Walk on the toes(+)
No fever
Denied trauma history
Father has URI symptoms recently,
but the patient did not
The patient did not received chemotherapy nor radiotherapy. There was no obvious recurrence signs during OPD follow up.

5. Physical Examination
Consciousness: clear General appearance: fair HEENT: conjunctiva: not pale, sclera: anicteric Neck: supple, no JVE, no LAP Chest: symmetric expansion, bilateral clear breath sounds Heart: regular heart beat, no audible murmur Abdomen: flat and soft, normoactive bowel sound, tenderness (-), rebound tenderness (-), muscle guarding (-), flank pain(-) Skin: no rashes Extremities: warm, pitting edema (-) *** No local erythematous change, no swelling over right hip No tenderness ROM: no limitation

6. Impression
Right hip pain, suspect osteomyelitis or septic arthritis, but malignancy cannot be ruled out

7. Image

8. Synovial fluid from right hip joint
Lab data

9. Kocher criteria Non-weight-bearing on affected side
Erythrocyte sedimentation rate > 40mm/hr
Fever > 38.5 °C
White blood cell count > 12,000

10. Treatment and clinical course

11. Final diagnosis
1. Right hip pain, favor reactive arthritis

12. Case 2 A 4-year-old girl Birthday : 2013/02/14
Date of admission : 2017/03/06
Chart number:172570xx

13. Chief complaint
Unable to walk with acute onset left hip pain after falling down at school on 3/04

14. Brief history
3/5 morning complained of left hip pain, 3/5 night cannot walk due to left side pain
No fever
No URI symptoms

15. Physical Examination
Consciousness: clear General appearance: fair HEENT: conjunctiva: not pale, sclera: anicteric Neck: supple, no JVE, no LAP Chest: symmetric expansion, bilateral clear breath sounds
Heart: regular heart beat, murmur(-),S3(-),S4(-) Abdomen: flat and soft, normoactive bowel sound, tenderness (-), rebound tenderness (-), muscle guarding (-), flank pain(-) Extremities: warm, pitting edema (-)
Swelling at left hip(+), Resist to PROM and AROM at left hip
No limitation or ROM at bilateral knee and ankle joint
Skin: no rashes, no petechiae or ecchymosis

16. Impression
Left thigh pain, suspect hip arthritis or fracture

17. Osteosclerotic mixed with osteolytic change at left intertrochanteric line.
Image (Plain film)

18. Image(CT)
1. Left hip synovitis with minimal amount of left joint effusion.

19. Image(CT)

20. Image(CT)

21. Image(CT)
Left hip synovitis with minimal amount of left joint effusion

22. Lab data

23. Treatment and clinical course
Pain control:
Voren 50mg/cap 0.25cap qid

24. Final diagnosis
Left hip synovitis

25. Review article

26. Clinical evaluation History:
Can bear weight or not/the pattern of limping /whether the limp is painful/ the duration of symptoms
Recent trauma or sports activities
Fever or associated chills
A history of recent viral illness of bacterial infections, including MRSA infections; recent weight loss; history of tick bites/ travel history
Inability or refusal to bear weight; obvious distress or agitation
Inconsolability
Holding the extremity in a fixed position

27. Physical examination Start with the nonpainful limb
Looking for skin erythema, swelling, ecchymosis, a laceration, or abrasion
Palpate the child’s back for tenderness at the paraspinal muscles and evaluate for tenderness at spinal processes (trauma, osteomyelitis, diskitis)
Examination of the plevis for skin changes and tenderness at the anterior superior and inferior illiac spines ( avulsion fracture of the satorius or direct head of the rectus)

29. Infection and inflammatory conditions
Septic arthritis of hip
Toxic (Transient) Synovitis
Damage to hip cartilage and blood supply to femoral head within 6-12 hours of onset
Self-limited virus-related synovitis
3 to 8 years of age group
Painful limp, fever, unable to bear weight, local swelling, erythema, joint effusions, limited joint motion
Most commonly preceded by a viral infection 2 weeks to 1 month ago
BT>38.5℃ , WBC> 12000/microL, ESR>40mm/hr, CRP>2.5mg/L
WBC, ESR, CRP within normal limits
Synovial fluid analysis:
WBC> 50000/microL, Seg>75%, positive Gram stain
S.aureus, S. pneumoniae, GBS, Kingella kingae
WBC 5000~15000/microL, negative Gram stain vs

30. Infection and inflammatory conditions
Osteolmyelitis and deep soft tissue infection
Fever and limping, worsen slowly over 1 to 3 days
Extrimity induration, swelling and fullness, local tenderness, painful range of motion of the hip, knee or ankle
Elevated WBC, ESR, CRP
Radiograph: may reveal only evidence of deep soft-tissue swelling until 7 to 10 days after onset
MRI with contrast to detect abscess, fascitits, myositis, and pyomyosistis

31. Infection and inflammatory conditions
Lyme disease
Spirochete(Borrelia burdorferi), transmitted by tick bite
Northest United states is most commom endemic area
Skin lesion, erythema migrans
Headache, mailaise, and fatigue
Acute onset arthritis, knee: most common
Erythema, an effusion in knee joint
Popliteal cyst

32. Infection and inflammatory conditions
Juvenile idiopathic arthritis(JIA)
Children younger than 16 years old
Joint pain, swelling without large effusions, and stiffness
Duration longer than 6 weeks
A limp and painful joint(oligoarticular), most commonly of knee
Multiple joint involvement(polyarticular)
Systemic symptoms
lethargy, loss of apppetite, more joint stiffness in the morning
Diagnosis: excusion, after traumatic and infectious causes have been r/o

33. Developemntal causes Hip diseases of Childhood, 3 most commom
Developmental dysplasia of the hip(DDH)
Legg-Calvé-Perthes Disease (LCPD)
Slipped Capital Femoral Epiphysis(SCFE)

34. Developemntal causes Developmental dysplasia of the hip(DDH)
Painless limp, abnormal gait or a leg-length discrepancy
Most cases are detected before walking age
Bilateral missed hips dislocation
Wide-based, waddling, Trendelenburg limp
Symmetric limitations of hip abduction of 40degree or less(normal abduction 50 degrees or greater)
Unilateral dislocation
Hop over the longer(normal) leg, walks on his/her toes on the shorter (hip dislocation) site

35. Developemntal causes Legg-Calvé-Perthes Disease (LCPD)
Idiopathic avscular necrosis of femoral head
Between 2 and 12 years of age, increased incidence in 6 to 8 years of age, more commom in boys than girls.
Painful limp, limited hip motion
Figure: 4-y/o boy, intermittent limping
for 3 months. Right hip severe flattening
of the femoral epiphysis

36. Developemntal causes Slipped Capital Femoral Epiphysis(SCFE)
Displacement of the proximal femoral(capital) epiphysis from the metaphysis of the femur
Causes: weak-ended physis
Endocrine/metabolic condition: hypothyroidism, renal osteodystrophy
Excessive of abnormal mechanical stress
Most common in children and adolescents between years, in obese children

37. NEOPLASMS Benign tumors: Osteochondroma Ostoid osteoma Malignancies:
Primary bone tumors, or blood cell tumors(leukemia, lymphoma)
Most commom: osteosarcoma, peak>10 years of age
The clinical presentations varies: intermittent limping, dull pain, rapidly enlarging mass, pathologic fracture
Night pain
Lethargy, fever, and weight loss

38. Overuse injuries
The site of inflammation is typically at the apophysis (a secondary growth center at the origin or insertion of the tendon)
Symptoms of overuse injuries may mimic more serious problems
Consider these diagnosis only after potentially more serious diagnosis (fractures, infection and tumors) have been considered and ruled out
Osgood-Schlatter disease (apophysitis of the tibial tubercle)
Sever disease (apophysitis of the calcaneus)

39. Thank you for your listening!